Template Injury Management System
This template will assist employers to devise an appropriate injury management system for their workplace.
Return to Work Program
This template will assist employers to devise an appropriate Return to Work Program collaboratively with the injured worker.
Workplace Rehabilitation Referral Form
This form can be used by workers, employers or treating medical practitioners to request a referral to a workplace rehabilitation provider.
Non-resident worker – incapacity declaration
This form is used to declare an injured worker’s incapacity when the injured worker does not reside in Western Australia.
Intention to reduce or discontinue income compensation – consent
This form is required if you and the worker consent to reduce or discontinue income compensation.
Intention to reduce or discontinue income compensation – return to work
This form is required if you intend to reduce or discontinue income compensation as a result of worker returning to work.
Intention to reduce or discontinue income compensation – medical evidence
This form is required if you intend to reduce or discontinue income compensation as a result of medical evidence.
Custody or imprisonment notice
This form is required if you intend to discontinue income compensation as a result of worker in custody or imprisonment.
Intention to dismiss worker notice
This form is required if you intend to dismiss a worker during the employment obligation period.
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for conciliation. An electronic version of the Application for Conciliation for use by unrepresented workers or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
Application for Conciliation
Complete this form to apply to have your dispute dealt with by the Workers Compensation Conciliation Service.
Statement of Social and Financial Circumstances
Complete and lodge this form with the Application for Conciliation when applying for; additional income compensation; or a standard increase in the medical and health expenses general limit amount; or an increase for special expenses in the medical and health expenses general limit amount.
Application for Order for Insurer to Make Payment
Complete this form to apply to the Director for an order for an insurer to make payment where the employer was previously directed to do so by a Conciliator.
Notice of Representation
Complete this form to notify the Director of your appointment or cessation as a representative.
Notice of Multiple Respondents
Complete this form if there is more than one respondent to the dispute and lodge it with the Application for Conciliation.
Notice of Discontinuance
Complete this form to notify the Director that you wish to discontinue conciliation of a dispute
Memorandum of Consent to Finalising Order
Complete this form to notify the Conciliation Service of the orders the parties have consented to in order to finalise the dispute.
Application for Order and/or Assessment of Costs
Complete this form if you wish to apply to the Conciliator for an order and/or assessment of costs.
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for arbitration. An electronically writeable and printable version of the appropriate application form for use by unrepresented workers, unrepresented dependants or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
Application for Arbitration
Complete this form to apply to have your dispute dealt with by the Workers’ Compensation Arbitration Service.
Application for Arbitration Workplace Fatality Compensation
Complete this application for a workplace fatality claim to be determined by the Workers Compensation Arbitration Service.
Application to Extend Time to Lodge an Application for Arbitration
Complete this form to apply for an extension of time to lodge an Application for Arbitration.
Statement of Social and Financial Circumstances
Complete this form and lodge with the Application for Arbitration when applying for additional income compensation or a standard increase in the medical and health expenses general limit amount and/or an increase for special expenses in the medical and health expenses general limit amount.
Reply to an Application for Arbitration
Complete this form to reply to an application for arbitration.
Certificate that Document was Given
Complete this form to certify you have given documents pursuant to the Arbitration Rules
Interlocutory Application
Complete this form to lodge an Interlocutory Application.
Notice Consenting or Opposing Interlocutory Application
Complete this notice to reply to an Interlocutory Application
Memorandum of Consent Order
Complete this form to seek consent orders from an arbitrator
Order for Production of Documents or Material
Complete this form and lodge it with an Interlocutory Application when requesting an order to produce documents.
Summons to Witness
Complete this form if you are seeking a summons to be issued by the Registrar or an arbitrator requiring the attendance of a person before an arbitrator.
Multiple Respondent Form
Complete this form if there is more than one respondent to the dispute and lodge it with the Application for Arbitration.
Notice of Representation
Complete this form to notify the Workers Compensation Arbitration Service of an appointment or cessation of representation.
Notice of Discontinuance
Complete this form if you wish to discontinue arbitration of the dispute.
Application for Order and/or Assessment of Costs
Complete this application if you wish to apply to the arbitrator or the Registrar for an order and/or assessment of costs.
Notice Consenting or Opposing Application for Order and/or Assessment of Costs
Complete this form in response to an Application for Order and/or Assessment of Costs.
Arbitration Order for Joinder of Party
Complete this form to give notice of an arbitrator’s order that another person be joined as a party to the proceedings.
